Care and support for people living with HIV/AIDS

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Prevention: daunting challenges aheadlooking into the genetic variability of the virus, which might affect the protection a vaccinecould confer.The information that scientists generate is in turn being used by the pharmaceutical andbiotechnology industry to develop “candidate vaccines” to be tested in HIV-negativehuman volunteers. The first human trial of an HIV-preventive vaccine was conducted in1987 in the United States. Since then, more than 30 small-scale trials have been conducted,including 12 in developing countries (Brazil, China, Cuba, Thailand andUganda). These trials, carried out with the participation of more than 5000 healthy volunteers,have shown that the candidate vaccines are safe and that they induce immuneresponses that could potentially protect people against HIV infection.The first large-scale HIV vaccine trials, designed to show whether the candidate vaccinesactually protect against HIV infection or disease, were launched in 1998 in theUnited States and in 1999 in Thailand. The trials involve 8000 healthy volunteers who aregiven one of two different versions of gp120, a protein located on the outside of thevirus, depending on the virus strains prevalent in the two countries. The initial resultsfrom these trials may be available within the next two years. In parallel, other candidateHIV vaccines are being developed through different experimental approaches. Some arebased on the HIV strains prevalent in developing countries. Most of these newer candidatevaccines will be tested in small-scale trials in human volunteers, and the best willproceed to large-scale evaluation for efficacy.Vaccine development is complicated not only by the range of virus subtypes circulatingbut by the wide variety of human populations who need protection and who differ, forexample, in their genetic make-up and their routes of exposure to HIV. Inevitably, differenttypes of candidate vaccines will have to be tested against various viral subtypes inmultiple vaccine trials, conducted in both high-income and developing countries. It isvital for developing countries to build up their technical and human capability to conductsuch trials with the highest ethical and scientific standards and with the full participationof the community.Most likely, the initial HIV vaccines will not be 100% effective, and they will have to bedelivered as part of a comprehensive prevention package. What is important now is toensure that countries where there is an urgent need for HIV vaccines participate in theglobal effort to ensure that a vaccine appropriate for their use is developed. Likewise, itis not too early to start planning how to ensure that a future vaccine is made available inthe areas of the world where it is most needed.In Asia, a clearly defined “gay” identity is even rarer than it is in Latin America. Thereis very strong social pressure on men to marry and father children, and men whohave sex with men are commonly married as well. This results in even higher levelsof potential “bridging” than those recorded in Latin America.In one study of truck drivers in India – men who spend long hours together on theroad – almost a quarter reported oral or anal sex with a man, and all of those said69
Report on the global HIV/AIDS epidemic – June 2000they also had sex with women. A study of men attending a clinic for sexually transmittedinfections in the southern Indian city of Pune showed that men reportingreceptive anal sex with men were 2.6 times more likely to be HIV infected than menwho reported no anal sex, even after taking into account other risk factors.In Thailand, the impressive success in reducing heterosexual transmission of HIV hasexposed a failure to focus on other important groups, including men who have sex withmen. In a study of military conscripts in an area of northern Thailand with a high prevalenceof HIV infection, 134 of over 2000 young men said they had sex with men andall but three of these men also had sex with women. The men reporting male–male sexwere nearly three times as likely to be infected with HIV as the men who had sex onlywith women, even after taking into account other factors such as sexually transmittedinfections. Although male–male sex was reported by less than 7% of the men, it wasresponsible for 13% of the HIV infections in this population in 1995.Box 15. Male circumcision and HIV infectionFor several years, researchers have been debating the relationship between male circumcisionand HIV. Several studies have indicated that circumcised men are lesslikely to become infected with HIV than uncircumcised men. However, because circumcisionis usually linked to culture or religion, it has been argued that the apparentprotective effect of the procedure is likely to be related not to removal of the foreskinbut to the behaviours prevalent in the ethnic or religious groups in which malecircumcision is practised. In addition, some researchers have assumed that anyassociation between circumcision and HIV must be complicated by the presence ofother sexually transmitted infections, which have been found to be more commonamong uncircumcised men.Clearly, the correlations are not straightforward. In the higher-income countries, therates of HIV infection among men who have sex with men do not vary greatly eventhough the circumcision rates do: few men in Europe and Japan but four-fifths ofmen in the United States are circumcised. In Africa, however, circumcision seems toconfer some protection. A study in Nyanza Province, Kenya, among men from thesame ethnic group, the Luo, found that one-quarter of uncircumcised men wereinfected with HIV, compared with just under one-tenth of circumcised men. The protectiveeffect remained even after other factors, such as sexual behaviour and sexuallytransmitted infections, had been taken into account. A study of over 6800 menin rural Uganda has suggested that the timing of circumcision is important: HIV infectionwas found in 16% of men who were circumcised after the age of 21 and in only7% of those circumcised before puberty. A recent review of 27 published studies onthe association between HIV and male circumcision in Africa found that, on average,circumcised men were half as likely to be infected with HIV as uncircumcised men.When African men with similar socio-demographic, behavioural and other factorswere compared, circumcised men were nearly 60% less likely than uncircumcisedmen to be infected with HIV.70
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Care and support for people living with HIV/AIDS

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